Salmonellosis Treatment & Management

  • Author: Alena Klotchko, MD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Sep 6, 2011
 

Medical Care

  • Salmonella gastroenteritis is usually a self-limiting disease. Fluid and electrolyte replacement may be indicated in severe cases. Because antibiotics do not appear to shorten the duration of symptoms and may actually prolong the duration of convalescent carriage, they are not routinely used to treat uncomplicated nontyphoidal Salmonella gastroenteritis. Current recommendations are that antibiotics be reserved for patients with severe disease or patients who are at a high risk for invasive disease .
  • Historically, recommended regimens for the treatment of typhoid fever included ampicillin, trimethoprim-sulfamethoxazole, or chloramphenicol. Emerging drug resistance over the past 20 years has limited the usefulness of these antibiotics. Presently, quinolone, macrolide, and third-generation cephalosporin antibiotics are preferred for empiric therapy pending sensitivities. Unfortunately, sensitivity to quinolones has been steadily declining, and these are no longer fool-proof agents for typhoid fever. A growing rate of resistance of nontyphoidal salmonella to nalidixic acid and ceftriaxone has been reported.[34]
  • Clinical data suggested reduced effectiveness of quinolone therapy in patients with nalidixic acid-resistant Salmonella strains.[35] A study of more than 1000 stored Salmonella isolates from Finland has confirmed earlier data that showed that resistance to nalidixic acid by means of disk diffusion is a sensitive and specific method of screening Salmonella isolates for reduced susceptibility to fluoroquinolones.[36]
  • Although uncommon in the United States, resistance to quinolone antibiotics among typhoidal and nontyphoidal salmonellae is increasingly common elsewhere. In one 22-year surveillance study in Spain, the prevalence of nalidixic acid resistance increased almost 80-fold to 38.5%.
  • In a recent review of US data from the National Antimicrobial Resistance Monitoring System, 58% of S typhimurium isolates isolated between 1997 and 1998 were resistant to at least one antibiotic, and 3 multidrug-resistant strains (resistant to ≥5 antibiotics) accounted for 74% of isolates.
  • Salmonella bacteremia is generally treated with a single bactericidal drug for 10-14 days. Given the resistance trends, life-threatening infections should be treated with both a third-generation cephalosporin and a fluoroquinolone until the susceptibilities of antimicrobial agents are known.[2]
  • If endocarditis or infectious arteritis is documented, urgent surgical treatment is usually necessary. Antimicrobial therapy for endovascular infections should be continued for a minimum of 6 weeks after successful surgery.
  • Years of therapy might be needed when surgery is not possible (eg, retained prosthetic devices, chronic bone and joint infections).[2]
  • For proven or possible CNS involvement, high-dose ceftriaxone would be the best choice for optimal penetration of the blood-brain barrier.[2]
Next

Surgical Care

Typhoid fever is occasionally complicated by intestinal perforation or hemorrhage, cholecystitis, endocarditis, arteritis, osteomyelitis, or soft-tissue abscess formation, necessitating surgical intervention.

  • Long-term S typhi carriage (usually with the gallbladder as the reservoir) may necessitate cholecystectomy.
  • Splenectomy may be required for splenic abscesses.[2]
  • Surgical care dramatically improves the likelihood of survival in patients with endarteritis, especially that which involves abdominal aorta. A review of 148 cases from 1948-1999 found a 62% survival rate in all patients treated with combined surgical and medical therapy and a 77% survival rate in 30 patients who were able to undergo extra-abdominal bypass with construction of an axillobifemoral graft.[37, 38]
Previous
Next

Consultations

Consultation with an infectious disease specialist should sought in cases of bacteremia, endovascular infections, CNS infections, and whenever typhoid fever is a strong possibility, as well as when antimicrobial resistance is suspected or documented.

Previous
Proceed to Medication
 
 
Contributor Information and Disclosures
Author

Alena Klotchko, MD  Fellow, Department of Infectious Diseases, Orlando Regional Medical Center

Disclosure: Nothing to disclose.

Coauthor(s)

Mark R Wallace, MD, FACP, FIDSA  Clinical Professor of Medicine, Florida State University College of Medicine; Head of Infectious Disease Fellowship Program, Orlando Regional Medical Center

Mark R Wallace, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Tropical Medicine and Hygiene, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary D Nettleman, MD, MS, MACP  Professor and Chair, Department of Medicine, Michigan State University College of Human Medicine

Mary D Nettleman, MD, MS, MACP is a member of the following medical societies: American College of Physicians, Association of Professors of Medicine, Central Society for Clinical Research, Infectious Diseases Society of America, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

John L Brusch, MD, FACP  Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance

John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Eleftherios Mylonakis, MD  Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital

Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Michael Zapor, MD, PhD, and previous coauthor David P Dooley, MD, to the development and writing of this article.

References

  1. Kim AY, Goldberg MB, Rubin RH. Salmonella infections. In: Gorbach SL, Bartlett JG, Blacklow NR, eds. Infectious Diseases. 3rd ed. Lippincott Williams and Wilkins; 2004:68.

  2. Hohmann EL. Nontyphoidal salmonellosis. Clin Infect Dis. Jan 15 2001;32(2):263-9. [Medline].

  3. Su LH, Chiu CH. Salmonella: clinical importance and evolution of nomenclature. Chang Gung Med J. May-Jun 2007;30 (3):210-9. [Medline].

  4. Brenner FW, Villar RG, Angulo FJ, Tauxe R, Swaminathan B. Salmonella nomenclature. J Clin Microbiol. Jul 2000;38(7):2465-7. [Medline].

  5. Grassl GA, Finlay BB. Pathogenesis of enteric Salmonella infections. Curr Opin Gastroenterol. Jan 2008;24(1):22-6. [Medline].

  6. Investigation of outbreak of infections caused by Salmonella saintpaul. Update for August 2008. Available at http://www.cdc.gov/salmonella/saintpaul/. Accessed 10/29/2008.

  7. Crum-Cianflone NF. Salmonellosis and the gastrointestinal tract: more than just peanut butter. Curr Gastroenterol Rep. Aug 2008;10 (4):424-31. [Medline].

  8. Brouard C, Espie E, Well FX , Kerouanton A, Brisabois A, Forgue AM, et al. Two consequtive large outbreaks of Salmonella enterica serotype Agona infections in infants linked to the consumption of powdered infant formula. Pediatr Infect Dis J. Feb 2007;26(2):148-52. [Medline].

  9. Centers for Disease Control and Prevention. From the Centers for Disease Control and Prevention. African pygmy hedgehog-associated salmonellosis--Washington, 1994. JAMA. Jul 26 1995;274(4):294. [Medline].

  10. Mermin J, Hutwagner L, Vugia D, et al. Reptiles, amphibians, and human Salmonella infection: a population-based, case-control study. Clin Infect Dis. Apr 15 2004;38 Suppl 3:S253-61. [Medline].

  11. Outbreaks of multidrug-resistant Salmonella typhimurium associated with veterinary facilities--Idaho, Minnesota, and Washington, 1999. MMWR Morb Mortal Wkly Rep. Aug 24 2001;50(33):701-4. [Medline]. [Full Text].

  12. Reptile-associated salmonellosis--selected states, 1998-2002. MMWR Morb Mortal Wkly Rep. Dec 12 2003;52(49):1206-9. [Medline]. [Full Text].

  13. Salmonellosis associated with chicks and ducklings--Michigan and Missouri, Spring 1999. MMWR Morb Mortal Wkly Rep. Apr 14 2000;49(14):297-9. [Medline]. [Full Text].

  14. Woodward DL, Khakhria R, Johnson WM. Human salmonellosis associated with exotic pets. J Clin Microbiol. Nov 1997;35(11):2786-90. [Medline]. [Full Text].

  15. Swanson SJ, Snider C, Braden CR, Boxrud D, Wunschmann A, Rudroff JA, et al. Multidrug resistant salmonella enterica serotype Typhimurium associated with pet rodents. N Engl J Med. January 4, 2007;356:21-8. [Medline]. [Full Text].

  16. World Health Organization Communicable Disease Surveilance and Response. Vaccines and Biologicals. Background document: The diagnosis, treatment and prevention of typhoid fever. Available at www.who.int/vaccines-documents/DocsPDF03/www740.pdf. Accessed 10/29/08.

  17. Meltzer E, Schwartz E. Enteric fever: an Israeli perspective. Isr Med Assoc J. Oct 2007;9(10):736-41. [Medline].

  18. Centers for Disease Control and Prevention. Preliminary FoodNet data on the incidence of infection with pathogens transmitted commonly through food--10 states, 2007. MMWR Morb Mortal Wkly Rep. Apr 11 2008;57(14):366-70. [Medline].

  19. Voetsch AC, Van Gilder TJ, Angulo FJ, Farley MM, Shallow S, Marcus R, et al. FoodNet estimate of the burden of illness caused by nontyphoidal Salmonella infections in the United States. Clin Infect Dis. Apr 15 2004;38 Suppl 3:S127-34. [Medline].

  20. Cavallaro E, Date K, Medus C, Meyer S, Miller B, Kim C, et al. Salmonella typhimurium infections associated with peanut products. N Engl J Med. Aug 18 2011;365(7):601-10. [Medline].

  21. Linam WM, Gerber MA. Changing epidemiology and prevention of Salmonella infections. Pediatr Infect Dis J. Aug 2007;26(8):747-8. [Medline].

  22. Crump JA, Luby SP, Mintz ED. The global burden of typhoid fever. Bull World Health Organ. May 2004;82 (5):346-53. [Medline].

  23. Bhan MK, Bahl R, Bhatnagar S. Typhoid and parattyphoid fever. Lancet. Aug 2005;366:749-62. [Medline]. [Full Text].

  24. Hathout S el-D. Relation of schistosomiasis to typhoid fever. J Egypt Public Health Assoc. 45;1970:145-56. [Medline].

  25. Bhutta ZA. Impact of age and drug resistance on mortality in typhoid fever. Arch Dis Child. 1996;75:214-7. [Medline]. [Full Text].

  26. Ali G, Rashid S, Kamli MA, Shah PA, Allaqaband GQ. Spectrum of neuropsychiatric complications in 791 cases of typhoid fever. Trop Med Int Health. 1997;2:314-318. [Medline].

  27. Prabha A, Mohanan, Pereira P, Raghuveer CV. Myocarditis in enteric fever. Indian J Med Sci. 1995;49:28-31. [Medline].

  28. Gasem MH, Keuter M, Dolmans WM, Van DerVen-Jongekriig J, Djokomoeljanto R, Van Der Meer JW. Persistence of Salmonellae in blood and bone marrow randomized controlled trial comparing ciprofloxacin and chloramphenicol treatment against enteric fever. Antimicrob Agents Chemother. May 2003;47:1727-31. [Medline]. [Full Text].

  29. Nakamura S, Iida M, Tominaga M, et al. Salmonella colitis: Assessment with double-contrast barium enema examination in seven patients. Radiology. Aug/1992;184:537-540. [Medline].

  30. Balthazar EJ, Charles HW, Megibow AJ. Salmonella- and shigella-induced ileitis: CT findings in four patients. J Comput Assist Tomogr. May/1996;20:375-378. [Medline].

  31. Puylaert JB, Van der Zant FM, Mutsaers JA. Infectious ileocecitis caused by Yersinia, Campylobacter, and Salmonella: clinical, radiological and US findings. Eur Radiol. 1997;7(1):3-9. [Medline].

  32. Bhutta ZA. Current concepts in the diagnosis and treatment of typhoid fever. BMJ. Jul 2006;333:78-82. [Medline]. [Full Text].

  33. Shirakava T, Acarya B, Kinoshita S, Kumagai S, Gotoh A, Kawabata M. Decreased susceptibility to fluoroquinolones and gyrA gene mutation in the Salmonella enterica serovar Typhi and Paratyphi A isolated in Kathmandu, Nepal, in 2003. Diagn Microbiol Infect Dis. Apr 2006;54:299-303. [Medline].

  34. Crump JA, Medalla FM, Joyce KW, Krueger AL, Hoekstra RM, Whichard JM, et al. Antimicrobial resistance among invasive nontyphoidal Salmonella enterica isolates in the United States: National Antimicrobial Resistance Monitoring System, 1996 to 2007. Antimicrob Agents Chemother. Mar 2011;55(3):1148-54. [Medline].

  35. Ercis S, Erdem B, Hasçelik G, Gür D. Nalidixic acid resistance in Salmonella strains with decreased susceptibility to ciprofloxacin isolated from humans in Turkey. Jpn J Infect Dis. Apr 2006;59(2):117-9. [Medline]. [Full Text].

  36. Hakanen A, Kotilanien P, Jalava J, et al. Detection of decreased fluoroquinolone susceptibility in Sal.onella and validation of nalidixic acid screening test. J Clin Microbiol. 1999;37:3572-77. [Medline]. [Full Text].

  37. Oskoui R, Davis W, Gomez M. Salmonella aortitis: a report of successfully treated case with a comprehensive review of the literature. Arch Intern Med. Feb 1993;153:517-25. [Medline].

  38. Nunes AP, Marques A, Marchado C, Meirelaes N, Sobrinho G, et al. Tiphymurium Salmonella Aortitis. Rev Port Cir Cardiotorac Vasc. Jul-Sept 2007;14:167-71. [Medline].

  39. [Best Evidence] Fraser A, Goldberg E, Acosta CJ, Paul M, Leibovici L. Vaccines for preventing typhoid fever. Cochrane Database Syst Rev. Jul 2007;3:CD001261. [Medline].

  40. Workman MR, Philpott-Howard J, Bragman S, Brito-Babapulle F, Bellingham AJ. Emergence of ciprofloxacin resistance during treatment of Salmonella osteomyelitis in three patients with sickle cell disease. J Infect. Jan 1996;32(1):27-32. [Medline].

  41. Berkley JA, Lowe BS, Mwangi I, Williams T, Bauni E, Mwarumba S, et al. Bacteremia among children admitted to a rural hospital in Kenya. N Engl J Med. Jan 6 2005;352(1):39-47. [Medline].

  42. Sinha A, Sazawal S, Kumar R, Sood S, Reddaiah VP, Singh B, et al. Typhoid fever in children aged less than 5 years. Lancet. Aug 28 1999;354(9180):734-7. [Medline].

  43. Aserkoff B, Bennett JV. Effect of antibiotic therapy in acute salmonellosis on the fecal excretion of salmonellae. N Engl J Med. Sep 18 1969;281(12):636-40. [Medline].

  44. Buchwald DS, Blaser MJ. A review of human salmonellosis: II. Duration of excretion following infection with nontyphi Salmonella. Rev Infect Dis. May-Jun 1984;6(3):345-56. [Medline].

  45. Crum-Cianflone NF. Salmonellosis and the gastrointestinal tract: more than just peanut butter. Curr Gastroenterol Rep. Aug 2008;10 (4):424-31. [Medline].

  46. Cunha BA. Antibiotic Essentials. Royal Oak, Mich: Physicians Press; 2005.

  47. Darwin KH, Miller VL. Molecular basis of the interaction of Salmonella with the intestinal mucosa. Clin Microbiol Rev. Jul 1999;12(3):405-28. [Medline].

  48. Edwards BH. Salmonella and Shigella species. Clin Lab Med. Sep 1999;19(3):469-87, v. [Medline].

  49. Finlay BB. Molecular and cellular mechanisms of Salmonella pathogenesis. Curr Top Microbiol Immunol. 1994;192:163-85. [Medline].

  50. Hathout S el-D. Relation of schistosomiasis to typhoid fever. J Egypt Public Health Assoc. 1970;45(1):145-56. [Medline].

  51. Helms M, Simonsen J, Molbak K. Quinolone resistance is associated with increased risk of invasive illness or death during infection with Salmonella serotype Typhimurium. J Infect Dis. Nov 1 2004;190(9):1652-4. [Medline].

  52. Hsu RB, Chen RJ, Chu SH. Risk factors for recurrent bacteremia in adult patients with nontyphoid salmonellosis. Am J Med Sci. Dec 2004;328(6):315-8. [Medline].

  53. Kennedy M, Villar R, Vugia DJ, et al. Hospitalizations and deaths due to Salmonella infections, FoodNet, 1996-1999. Clin Infect Dis. Apr 15 2004;38 Suppl 3:S142-8. [Medline].

  54. Kotloff KL. Bacterial diarrheal pathogens. Adv Pediatr Infect Dis. 1999;14:219-67. [Medline].

  55. Lax AJ, Barrow PA, Jones PW, Wallis TS. Current perspectives in salmonellosis. Br Vet J. Jul-Aug 1995;151(4):351-77. [Medline].

  56. Marimon JM, Gomariz M, Zigorraga C, et al. Increasing prevalence of quinolone resistance in human nontyphoid Salmonella enterica isolates obtained in Spain from 1981 to 2003. Antimicrob Agents Chemother. Oct 2004;48(10):3789-93. [Medline].

  57. Mead PS, Slutsker L, Dietz V, et al. Food-related illness and death in the United States. Emerg Infect Dis. Sep-Oct 1999;5(5):607-25. [Medline].

  58. Mermin JH, Townes JM, Gerber M, et al. Typhoid fever in the United States, 1985-1994: changing risks of international travel and increasing antimicrobial resistance. Arch Intern Med. Mar 23 1998;158(6):633-8. [Medline].

  59. Miller SI, Pegues DA. Salmonella species, including Salmonella typhi. In: Mandell, et al, ed. Principles and Practices of Infectious Diseases. Vol 2. 5th ed. 2000:2344-62.

  60. Nelson JD, Kusmiesz H, Jackson LH, Woodman E. Treatment of Salmonella gastroenteritis with ampicillin, amoxicillin, or placebo. Pediatrics. Jun 1980;65(6):1125-30. [Medline].

  61. Rabatsky-Ehr T, Whichard J, Rossiter S, et al. Multidrug-resistant strains of Salmonella enterica Typhimurium, United States, 1997-1998. Emerg Infect Dis. May 2004;10(5):795-801. [Medline].

  62. Schroeder CM, Naugle AL, Schlosser WD, et al. Estimate of illnesses from Salmonella enteritidis in eggs, United States, 2000. Emerg Infect Dis. Jan 2005;11(1):113-5. [Medline].

  63. Van Immerseel F, Pasmans F, De Buck J, et al. Cats as a risk for transmission of antimicrobial drug-resistant Salmonella. Emerg Infect Dis. Dec 2004;10(12):2169-74. [Medline].

  64. Voetsch AC, Van Gilder TJ, Angulo FJ, et al. FoodNet estimate of the burden of illness caused by nontyphoidal Salmonella infections in the United States. Clin Infect Dis. Apr 15 2004;38 Suppl 3:S127-34. [Medline].

  65. Wain J, Diep TS, Ho VA, Walsh AM, Nguyen TT, Parry CM, et al. Quantitation of bacteria in blood of typhoid fever patients and relationship between counts and clinical features, transmissibility and antibiotic resistance. J Clin Microbiol. Jun 1998;36:1683-7. [Medline]. [Full Text].

  66. Weinberger M, Andorn N, Agmon V, et al. Blood invasiveness of Salmonella enterica as a function of age and serotype. Epidemiol Infect. Dec 2004;132(6):1023-8. [Medline].

 
Previous
Next
 
Rose spots on abdomen of a patient with typhoid fever due to the bacterium Salmonella typhi. Courtesy of CDC/Armed Forces Institute of Pathology, Charles N. Farmer.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.